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Overview

Health care providers should consult TB experts when treating patients with drug-resistant TB disease.

Health care providers should review comorbidities, current medications, and the results of drug susceptibility tests to choose the appropriate medications for treating each patient.

Treatment regimens should include only drugs to which the Mycobacterium tuberculosis isolate have documented or high likelihood of susceptibility. Treating patients with TB disease with drugs to which their strain of TB is resistant may lead to poor clinical outcomes and acquired resistance to additional drugs.

Guidelines

For more information on the treatment of drug-resistant TB disease, please refer to:

Treating patients with drug-resistant TB disease

A treatment regimen for drug-resistant TB disease should only include drugs to which the patient's M. tuberculosis isolate is susceptible. Sometimes a temporary regimen is used for treatment based on clinical and epidemiologic information available while awaiting drug susceptibility test results.

A patient's treatment regimen may depend on factors including:

• Drug-drug interactions,
• Comorbidities,
• Patient preferences,
• Harms and benefits associated with the drugs,
• Ability to appropriately monitor for adverse effects, and
• Drug availability.

Treatment duration will depend on the clinical context, extent of disease, response to treatment, and other factors. Directly observed therapy is recommended to ensure treatment completion and monitor for adverse events. Consult treatment guidelines for information on clinical monitoring.

Treating patients with isonaizid-resistant TB disease

Patients with TB disease that is resistant to isonaizid only (sometimes referred to as isonaizid monoresistance) should be treated with a 6-month daily regimen of:

• Rifampin,
• Ethambutol,
• Pyrazinamide, and
• A later-generation fluoroquinolone.

In certain situations, the duration of pyrazinamide can be shortened to two months.

Treating patients with rifampin-resistant or multidrug-resistant TB disease

Multidrug-resistant TB (MDR TB) disease is caused by TB bacteria that are resistant to at least isoniazid and rifampin.

BPaLM and BPaL treatment regimens

Health care providers can use a composed of bedaquiline (B), pretomanid (P), linezolid (L), and moxifloxacin (M) for people aged 14 years and older with rifampin-resistant, fluoroquinolone-susceptible pulmonary TB disease.

For people aged 14 years and older with rifampin-resistant pulmonary TB disease and fluroquinolone resistance or intolerance, health care providers can use a of bedaquiline (B), pretomanid (P), and linezolid (L).

BPaLM and BPaL regimens are used in people who have had no previous exposure to bedaquiline and linezolid or have been exposed to these drugs for less than 1 month. BPaLM and BPaL are also treatment options for people with an intolerance of rifampin.

Patients treated with BPaLM or BPAL are recommended to be monitored for two years after treatment completion.

Other treatment options

People initiating treatment for MDR or rifampin-resistant TB but ineligible for BPaL (e.g., resistance or intolerance to bedaquiline, pretomanid, or linezolid; severe extrapulmonary TB; pregnant; lactating; or aged less than 14 years) can receive an individualized regimen based on the 2019 guidelines .

Treating contacts of patients with drug-resistant TB disease

If a person with latent TB infection is a contact of a patient with isonaizid-resistant but rifampin-susceptible TB disease, a 4-month regimen of daily rifampin may be recommended. If a person with latent TB infection is a contact of a patient with rifampin-resistant but isoniazid-susceptible TB disease, a 6 or 9 month regimen of isonaizid may be recommended.

Based on the drug-susceptibility test results of the source-case isolate, contacts presumed to have been infected with MDR TB may be treated for 6–12 months with a later-generation fluoroquinolone alone or with a second drug.

Depending on the drug resistance profile, health care providers should consult with an MDR TB expert to evaluate the best options for MDR latent TB infection management. TB programs or the TB Centers of Excellence for Training, Education, and Medical Consultation can provide assistance and support.

Resources